Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Thursday, December 06, 2007

One of my colleagues took care of a "trap" patient the other night. A "trap patient" sets up the doc and ER staff for failure by looking and acting like a dirtball, but is, inconveniently, tremendously ill (boy who cried wolf etc...).

This patient had been seen in our facility a few times, and at other surrounding ERs within the past ten days. She is 26 years old. Her angry, multiply tattooed, smelly, drunk boyfriend had the paperwork to prove it. He waved said paperwork in our faces while letting us know with various grunts, groans, and hand gestures that he thought we were all stupid. The patient 'hurt everywhere' and 'needed pain medicine' and she was cold. She was a drug-seeker and the nurses told us so. They even set her back in a fast-track bed and told my friend, "Get her out of here... She was just here last night!"

My friend was all set to do just that but he took a look then showed me the chart while raising one eyebrow. He was concerned that the patient's heart rate was 120 and that the patient had a fever and that the patient's blood pressure was a bit low. My buddy worked this young gal up, AGAIN, and took a good ration of shit from the nurses for it too.

Well, the labs started coming back. White count 21,000, not pregnant, ESR ("sed rate") 75... and some other stuff. Normal Xray. Normal CT of the abdomen from an outside facility three days prior. Nothing making sense (but sepsis or connective tissue disease jumping up on the list above "dirtball" now).

The patient herself was absolutely no help. She denied any and all risk factors for transmissible disease, denied drug use, denied high risk sex, all that stuff. That sed rate though, that white count, those vitals... she WAS sick. She DID "hurt all over" and she HAD BEEN a drug seeker. The admitting physician gave my pal a rash of shit for dropping a "weak admission" on him.

Flash forward two days. Little miss puzzle has been transferred from our facility to the Mecca... for a possible aortic valve replacement. Turns out she nearly died soon after admission. Turns out, well, just one time, she used IV drugs. Turns out she had endocarditis with a big goomba on her aortic valve and tons of nasty bacteria coursing through her blood. Turns out she may also have HIV and maybe Hepatitis C too. Turns out she really was a dirtball, and a liar, and a very sick gal who may still die.

I had the exact same thing happen recently! A known drug seeker who was in and out of our ER for days and days and almost always left after crying and stomping around and manipulating the staff...turned out to actually have pneumonia. She was put in my area and I actually got concerned when after she was there an hour without being seen and I hadn't heard a peep out of her. Went over to assess and her 02 sat was 89 on room air, she had a fever of 104 rectally, and her lungs sounded like crud.

She was actually sick and spent that hour resting and sleeping in her stretcher. Who knew?!

"Drug seeker" is not a diagnosis, it is a presentation. We tend to dismiss these patients because they are such a pain in the, ahem, neck, and a threat to our licenses, and; well you know what I mean.

The problem is, we forget to ask the necessary question: WHY is this patient seeking druds? Just because they like the high? weell, yes, often that id the case. However, sometimes patients are seeking drugs becaus they are sick or injured, need releaf, but lack the social skills to communicate their needs effectively. Or, maybe they are really sick, but have been turffed out by doctor after doctor, and are looking for someone to take the time to find out what is wrong with them.

Always ask, WHY is this patient seeking drugs on this occasion, and don't blind yourself with shallow stereotypes.

Sermon from the dog above duly noted and flushed down the commode. Any ED doc worth his spit knows that these dirtbags (yes, dirtbags) are the biggest land mines in the world, and have the most litigious families you could find. So I usually work them up to the hilt, knowing that they are lying about drug use and every thing else. (Had one who denied drug use last week who went to the OR to remove 3 broken needles from her arm). I'll let the social worker without 4 urgent patients that just hit the door figure out the "reasons " for their dirtballness and drug seeking.

I've gotten to the point where I tell the drug seekers and "dirtballs" that if they cry wolf enough, when they really need help nobody is going to believe them. I know they don't give a rat's a$$ about what I have to say but it makes me feel better and that's really all that matters!

Shrodingers right on this one. If they are willing to stay once I tell them I'm not giving them narcotic pain meds then they get a full w/u time after time. If they walk or out actually wait long enough to sign out AMA then its on them.

But if she hadn't lied at the outset, she might actually have had a hope in hell of convincing someone she was ill. As opposed to having to wait and hope that an overworked doctor would be compassionate and bright. It's all in the attitude. The attitude of entitlement will get you pissed off medical workers every time.

The attitude,"I have used IV drugs, but now I really feel bad compared to my usual bad and doctor please help me" will help defuse the whole pigeon-holing that can happen. Being a pain in the arse is not a good thing. And won't get you better care.

Although he/she spells like my 4 year-old, countydog has a valid point: if you treated the 'whole person' as opposed to the 'junkie', you may have made a more rapid diagnosis and actually helped this person deal with the issue that made her a 'dirtball'. She probably had a heart murmur that was overlooked because she was 'too gross' to examine properly (goomba = murmur). Take some time and consider countydog's comment instead of dismissing it as ridiculous.

as you may recall from the post my friend had to fight with our hospital physician to get this patient admitted. the ER stay was two hours in which time the differential was narrowed from "dirtball drug seeker" which is a LABEL THAT OUR TRIAGE NURSE GAVE THE PATIENT to "undiagnosed connective tissue disease or sepsis or HIV or some combination of the above". if you, like your friend, could comprehend the written word a bit better you would understand that kinda like the WHOLE FREAKING POINT OF MY POST is that ER physicians, especially, can not be prejudiced by labels, ie. "Dirtballs Get Sick Too." geez. so, with the utmost kindness, FUCK YOU AND THE HORSE YOU RODE IN ON YOU FREAKING MONDAY MORNING QUARTERBACK RETROSPECTOSCOPE-LOOKING BLEEDING-HEART WASTE OF CARBON.toodles

Breathe...OK....in, out, in...repeat. Chill out, man. I CAN read, my friend. My point was not to bash anyone. Although you SAY you didn't label this person, that is exactly what you did. I would bet alot of money that this person did not get a good chest exam because the docs thought this person was a disgusting scumbag. Everything you wrote about the process of diagnosis depended on vitals, lab tests and radiology - no mention of physical exam was noted (yes, I did read the post carefully). You (like all of us) are blinded by prejudice - but that doesn't mean we can't learn from our shortcomings. Peace brother.

i hereby label you annoying. the physical exam did not make the diagnosis... the labs pointed in the right direction, but no murmur was heard and the vegetation was only picked up on TEE but all of that is really beside the point which was, to congratulate a colleague on dodging a bullet that could have cost him heartache, money, time, and lost sleep and to point out that this DIRTBALL was manifestly treated like he DESERVED THE BEST CARE IN THE WORLD and was diagnosed IN SPITE OF HIS LIES. pretty good job my colleague did and a credit to him and his training. the nurses missed it.

the trick of the ER is to not be fooled by labels (to beat a dead horse). i'm just a bit tired of patients like this and their defenders. this patient made choices. they were bad choices. the choices they make, of their own free will, may kill them IN SPITE OF THE FACT that my colleague did an absolute bang-up job catching them at the precipice of death.

oh, they had no insurance. oh, we will lose lots of money on her as will the referral institution. oh, your taxes will go up as well as your insurance rates becuase of patients like this. oh, she WAS A DIRTBALL, AND A LIAR, and so are we all.

life is hard. it's harder when you are stupid. it's much harder when you are a STUPID DIRTBALL LIAR IV DRUG ABUSER and have your behavior and choices excused by the feel-good philosophy of the day. my WHOLE FREAKING JOB IS TO LABEL, JUDGE, AND DECIDE and to do it perfectly or land in court.

i think my anger is justified, besides, you have not begun to "look past my anger" and find out about "why i am angry" and i believe you have, well, labelled me. go smoke some more pot.

I don't interpret either of the objects of you anger as being particularily judgemental og the doc or the care, they just don't see what we see day in and out and are liberal, democrat, tree-hugger types who may one day either bleed out of their hearts or "see the light"

For you two guys, we, as a specialty, have volunteered to see and treat everyone who shows up regardless of their ability to pay or tell the truth, and this was a very typical patient for us and the ED doc did a damn good job of "fighting" for this dirtball.Murmurs, even those of Aortic veges are terribly hard to hear in an ED. I will bet U $100 the doc listened for it, just couldn't hear it.

The point of the post was "just because they're a dirtball doesn't mean they can't be sick". U have to address the vital signs, which he did most appropriately and thereby made an astute call which was not popular with his working nurses nor the consultant who got "dumped on"..In spite of his being ridiculed, he persisted on in doing the right thing for this POS and ultimately may have saved her life. And allowed her further years to abuse the health care system and cost us all $$ by her choices. It is very hard for me, at least, to drum up much sympathy/empathy for any self inflicted disease such as this and I suspect most of us in the trench will agree..So, HTFU!!

Trix is right. We should treat the WHOLE dirtball, not just the revolting outside. If we would just look deeper we could have made the diagnosis sooner, and gotten this burden back on her feet in no time. Ah, the choices we make in life.

911:I think I can look past your anger to the 'why'. You are pissed off because you treat people who you deem beneath you. This is unfair because you are a hard worker who pulled himself up by his bootstraps and thinks we all should do the same. You are mad because you waste your time and taxes to help people that you hate. Remove the HATE from this equation and I bet you wouldn't be angry at all. This story you told would be a simple one of a human being who came seeking help and WAS helped.

It's not so much the wasting time and taxes--which is annoying, but folks like Trix saying we should be NOT be angry about the waste. That Judgement is WRONG. Some of these life choices are bad. Some have bad consequences. Realizing that is reality.

oh the joys of baitint bleeding heart morons. where do i start? okay, first, 'remove the hate'. okay, done. second, 'smoke more pot'. okay, done, and whoa, dude! i'm like going to the al gore global warming rally and putting a cork in my ass so i can quit farting and adding to the greenhouse problem... cool. does anyone have some chai tea and some pizza? cool. i hate george bush, it's his fault after all, and dick cheney, and those Christians. remove the hate. yeah dude, got it. the only hate i'm feeling right now dude, with this super mellow buzz, is FOR YOU YOU SHITBRAIN. please patronize other blogs or just go back to the daily kos. one more time for effect, FUCK THE HELL OFF!.cheers

I am going to throw my hat in with the dog who can't spell, anon, and trix on this one...sorry to disappoint you guys.

The next time I get a drug seeker, chronic invisible and undiagnosable pain, and multiple symptom patient.....I am gonna get to know them. (Which will probably happen about 3 times tomorrow.)

Screw the 15 people waiting to be seen, the STEMI and the trauma patient. Screw the transfer center with the DKA at the outside "vetrinary" ER. I'm gonna sit down and get to know my chronic pain patient. I will ask about his/her childhood and what led them to their current state. I will inquire about their failed relationships and how they affected and effected the poor soul.

I'm gonna get to know this person in need because I'm a healer and because I care. If one of the sick patients codes while we're bearing souls, the nurse will surely call me and I can pardon myself while I deal with that and then go back for more of the "getting to know session".

Screw the multiple family members who want to know the status of their loved one and the innumerable calls from other physicians.

I have a higher calling. I wanna get to know my drug seeker and understand them. I'm sure they are wonderful people and they truly belong in the ED where I can take the time to explore their inner thoughts and feelings and deal with their emotional needs (after of course I give them their drug of choice so they'll stop screaming).

Anon, dogspeller, and trix....I hope one of your family members is amongst the many that'll be waiting on me to appear in your room. You will be able to remind your family member that ER docs have an important duty to get to know and understand their drug seeking patients.

I look forward to my morning shift with a new sense of feeling now. I'm tingling all over because I now realize that my job isn't about seeing volumes of patients, identifying the sick from the non-sick, and making room for new patients. It's about getting to know my frequent flyers innermost hopes and dreams.

BTW: good job 911. I have worked in a place with rampant endocarditis and a murmer was only present about 70% of the time. In my current ED, I'm lucky to hear S1 and S2 it's so noisy.

Yep, for every turkey there does come a Thanksgiving. It's hard to sort 'em out. As one of my favorite attendings used to say: "it's a mine field out there doctor".

I am sad that medicine has become so hopeless and cynical. This is why the public trust in physicians has evaporated. One of these 'scumbags' may be a good person who just needs someone to care about them even if they don't 'deserve' it. This is the type of doctor that can change lives. You may all be good ER docs, but you seem to have lost your humanity.

Here's an idea for you, Trix. Why don't you go down to your local biggest hospital ED and volunteer your time to do what you are suggesting we should? And why don't you take, oh, about 30 of our "patients" home with you and nuture them, feed them, bathe them, and make them cookies and milk? And then, after they've stolen everything in your home, probably raped you and your family because you didn't have enough drugs or money for them to buy drugs and beaten the shit out of you and yours, then why don't you go back to your local ED and seek help for your injuries while 85 and 911 are both taking care of the scumballs who just left you for dead and they(85/911) are now trying to get in touch with the scumballs "inner person" who, of course" just needs to be understood and put back on the path to self-enlightenment in order to become a productive member of YOUR society?In case you don't get it, just one more time, FUCK OFF

I got to try the new touchy-feely technique today! An inpatient at a local psych unit complained of chest pains (review of his record showed that he had had "8, 9 and 10of 10" back pain during his entire psych hospitalization for suicidal ideation and drug abuse). He told me that he'd had chest pains before, and the only thing that relieves them is Demerol. I denied his Demerol request, but told him that I loved him as a human being and I wanted to know more about his hopes and dreams in life. He said "Fuck you" and stormed out.

So my first test of the touchy-feely approach to dirt-balls didn't go well. But I'll keep trying since I want to respect their humanity.

Trix...I love the Oldfart's suggestion. Come join us for a while and see WHO we're talking about and WHY before you condemn all docs as cynical for no reason. A little reality thrown into your theory shouldn't hurt.

Truth be told, most of the patients I see are wonderful folks. This whole thread has been about the dirt-ball patients which is the minority of the people we see. That was the point!

I have to laugh because I am happily far, far away from the ER now and happily ensconced in the Trauma ICU where 16 year olds go to die after crashing their cars while high.I too used to get pissed off about dirt bags,liars, and drug hounds. Now, I just don't give a shit.At this point I don't care about anything my patients have ever done or will ever do. I don't care if they eat up resources. I have to come to the happy realization that it ain't my money they are spending and they mean nothing to me. They are not a friend or family so I don't have to give a shit whether they live or die.All I have to do is perform according to the College standards of care and follow the guidelines my hospital demands. As long as I chart nicely and follow the protocols I am covered by my hospital.Nowhere does it say I have to give a shit about their lifestyle.

It is amazing how much stress disappears when you stop caring about assholes. The fact that you still get so damn angry means you still care way too much. Give it up, it'll make you a much more cheerful person.

Heres my story, any advice would be greatly appreciated. I am about to be 30yrs old, and I work(ed) in a warehouse. I had barely statred this job and not even 2 weeks later I was was driving a Tugger Machine (that pulls carts) I had got to my aisle to unload boxes and stepped off the machine to pull the brake up when the machine malfunctioned,and went in reverse crushing my tibia and shattering my fibula. I was pinned up against 7 stories of shelves while the machine continued to run over the top of me. I am on workers comp, and was taken to ER,(8-2-2007) treated by surgeon on call, who did not want to do a surgery at that time, instead had me in a full leg cast, and told me to follow up with him, so I did. Almost 3 weeks later (8-22-07)the dr. told me the bones were not healing the way he wanted and insisted on surgery, so I ended up getting 8 screws and a metal plate in my right leg. After my dismissals from the hopsitals he had me on Darvocet for pain, and it was not helping, so he switched me to Hydrocodone 7.5mg. The instructions were to take 1-2 pills by mouth every 4-6 hrs for pain, which I was in alot of. He prescribed me 20 pills at a time so it was a 3 or 4 day supply. I had continued to see him, and still to this day have alot of pain (though some days are worse than others) however after a while he stopped treating my pain and refused to give me anything, just told me to take ibuprofen, so I did~It did not help. I was taking sometimes 8 or 9 of the a day, but no relief. I tried to talk to him about this and how much I was hurting but it was as though he was hearing me, but not listening to me. The pain got so bad at times, I was taken to the ER for treatment, though I had a treating dr. for this injury. I've been going to appts now for 5 months and at least the last 4 everytime, I was in and out of the exam room in ten minutes tops, he would take an x-ray, and dismiss me. He explained to me there is NO way I am in any pain because MY LEG IS HEALED. I know how much pain I have, but he did not seem to care. I then got a letter a few days ago to go to a different Dr. for my impairment rating, not knowing what to expect. However I went to see that Dr. and he was in shock that I had been in NO kind of Physical Therapy (though I had even asked my treating dr. that several times, and he told me it was not needed) Imp. Dr had my medical records (which I had also gone to pick up before my imp. rating appt.) and he said that "HE WOULD HAVE TO DISAGREE THAT I AM HEALED, AND I AM NOT AT MMI. HE STATED IT WOULD BE AT LEAST ANOTHER 9 MONTHS TO A YEAR BEFORE I AM COMPLETELY HEALED." He advised me that I should consider finding me another Dr. who is going to treat my pain, and get me into therapy and make sure that I am taken care of. After reading my medical records, I called my treating Dr. and my attorney and I requested another Dr. However, in my records Dr. M (treating Dr.) stated false accusations about me, for 1 saying that I had lied to him about having to go to the ER for treatment,(I had the discharge papers for proof) he also stated that I was abusing narcotics by taking too many of them, though I took them as directed on the bottle. I have been reading up on some things that my attorney had told me, and I never knew it existed, but my Dr. was blacklisting me, which is illegal. I was not only mad as hell but I was hurt and felt betrayed. I did everything he asked of me as a patient, and he never discussed any of these matters with me in person. Him and the staff would smile in my face and obviously talk behind my back. So my attorney found me another Dr. but I had to drive today for 3 hrs to get there because of my insurance (Network Dr.s) and that alone was a task in itself to get there, and once again, I was handed IBUPROFEN, and told to come back for therapy in 1 week~I AM IN SHOCK! How can this happen to patients? I understand that yes, there probably are people who misuse a narcotic, but I AM IN SEVERE PAIN, and its as though my Dr. has ruined me for a fair treatment. I was not taking them for the fun of it, but because I can barely even stand up to get out of bed sometimes, and if the weather is cold, I can not go outside because it hurts even more with the hardware in my leg. I have NEVER had any problems with any drug or alcohol problems in my life, because I choose not to do those things, I've seen what it does to people. I dont even like to take a tylenol when I have a headache, but I have no choice when my leg is swollen 3 times bigger than it should be, and in pain 10+ on a scale. I have worked in corrections for many years, and been in the military~so why am I being treated this way? It's just not fair, and I don't know what I need to do next. All I want is to be treated like any other patient, and get respect from a Dr. that I am comfortable with, but that Dr. has ruined my judge of character, and I am furious because it seems as though I am crying out for help,and only getting jerked around from not only my Dr. but my workers comp insurance as well, I would give anything to not have a broken leg but I can't change it. Now I am stuck with this hardware in my leg, ugly scars, and not to mention by self being, depression, stress, and will never be able to do all of the things that I did before. I feel helpless, and just need some advice from any dr., or someone else who may have gone thru something similar... I am about to just give up but its not fair that this can happen to patients, especially those who have no history of abuse and who really are hurting. They are getting paid to treat me, but I barely even get 5 minutes with them~What do I do?!? Please help! Thank you in advance for reading my story. Hope you are starting off 2008 better than I am!

Please Lord, let me never get '911 Doc' as my ER physician. You, Sir, are an ass, and a pompous one at that. You represent yourself as a young, egotistical twit who, believing that your years of rote memorization and (probably pathetic) level of diagnostic skill make you a God presume to pontificate over the lives and deaths of all us inconvenient 'meatsacks' who distract you from trying to nooky up the nursing staff and suck down coffee while browsing Youtube between 'dirtbags'.

There are hundreds of reasons a person might be drug seeking, and most of them have nothing to do with being a dirtbag. Many of them, in fact, have quite clearly to do with NEEDING something...and not as a 'fix'. Have you ever heard of chronic pain? Let me tell you something, buddy: After living through a horrendous car wreck, I have spent nearly a decade with continuous, variable pain in most of my body that seems to have little to do with my original injuries but is, rather, related to dysfunction of the nervous system because of brain trauma, spinal cord damage, and stenosis in my lower spine...all of which were damaged.

But to YOU, in your hospital ER..all YOU would see is that I am perhaps not entirely clean or 'pretty smelling' (because I have trouble taking care of myself most days, literally), that my hair is unkempt (same reason. I often have trouble sitting through a haircut without needing a lie down), and that I might seem a tad overenthusiastic about my symptoms...which, being SICK TO DEATH OF THEM, I most certainly am.

Take a lesson from me, a patient, and a former nursing student if you won't take one from your other...and I dare say BETTER colleagues...either grow a bedside manner and have surgery remove some of that snide ego of yours, or get the HELL out of this business before you end up with a murder charge against you for negligence.

If you 'Doctors' are having such a hard time dealing with people, perhaps you could at least listen to your nursing staff...whose job it is to not only carry out your orders for treatment, but to actually CARE for the patient. If a nurse thinks the patient is a dirtball, and the nurse is generally not a jackass from the getgo but rather a caring individual, then its a good bet the patient really IS...a dirtball. But you as a doctor dont have the right to dismiss a patients expressed concerns, either morally or legally, based on a character assessment that has not been borne out by documentation.

In the case of the patient in 10 ER's in 2 days, there you go..there is your documentation and no one can fault you for your assumption, but in most cases, your snap judgement does nothing more than assure that this patient will die...somewhere other than your ER bed as you kick them out the door to die on the street or at another hospital for lack of very real, very needed care that you could not provide because you were too busy dismissing them as a 'dirtball'.

If giving out pain meds pisses you off so much...then don't do it. Instead explain to the patient WHY you won't do it, and give them the option of recieving treatment WITHOUT pain intervention on a massive scale.

Dudes, if I have a knife stuck in me, I'd rather you yank it out and sew me up while I scream bloody murder than have you not sew it up at all. Verste?

Maybe I was a bit too angry in my last comment, but you know, somewhere in the health care network at a hospital there has to be a point where the bullshit stops on BOTH sides of the gurney.

The patient OWES you an honest recitation of what ails them as best they can convey, and you owe THEM your paycheck, your car, your house, and the model you are boinking on the side.

I recieve most of my care through the Veterans administration, and I have dealt with my fair share of folk who think all us 'damned vets' are drug seekers, hippies, burnouts and crotchety old farts who are too stupid to take care of ourselves, but I have also dealt with a number who UNDERSTAND our reasons for acting in these manners.

Flat out, once you have stared death in the face and shaken his hand on a battlefield...everything else kinda..pales in comparison and your body becomes almost an extra appendage rarely noticed, while the mind...the mind becomes the center of your existence.

For the veteran that means little inconveniences like massive pain, inability to breathe, etc. are secondary to our trying to enjoy what is left of a pale, hollow life to the best of our ability..by smoking...drinking..having sex...doing drugs, etc. Is it defensible? no. Is it excuseable? no. But it is understandable, and you must at least have enough compassion to understand WHY those of us who had our asses shot off in YOUR defense would act this way.

Much of the time, the only reason we come to see you is because we either had a mental relapse that caused us to momentarily give a crap about our bodies, or because our families forced us to see you. We don't like doctors much because you rarely solve our problems, instead you 'stave them off for a while'. You tend to shove pills down our throats and dismiss us instead of doing things that actually help us like those damned inconvenient 'unecessary' surgeries...hip replacements...stents...pacemakers...you know..stuff that while it doesn't PAY YOU VERY WELL TO DO tends to improve and prolong our lives because you are too busy worrying about getting burned out or getting sued when you piss up and kill someone.

feel better anon? i thought not. we can easily reach an agreement however... you stay out of my ER and i won't be your doctor.

i know this will be lost on you but you just expended quite a bit of anger and energy typing your rant. even though this post was about a specific patient that was certainly not you it evidently hit a bit close to home.

you rail and scream at me for calling a particular patient who was proven to be a liar and who was proven to have cost the taxpayer tens of thousands of dollars by lying

exactly what he was and i then go on in fair detail that in spite of this fact, and in spite of the fact that he did not deserve the best care possible (unless liars deserve to have their lies believed), that the beat care possible is exactly what he got, and kindly.

in fact, were he to read this post he would not recognize himself as patients like him tend to find fault with everyone they know, but can not see it in themselves, which leads me back to you.

i will pray for you because I believe it may be all that's left. i'm afraid you may be terribly lonely and are puzzled as to why. the answer is in your post because while railing at me for calling an anonymous patient a 'dirtball', evidently demonstrating your dislike name-calling (though emminently supported by the facts of the case), you revile me, a physician whom you do not know, with the most hateful name-calling in my recent memory.

in short, you are a hypocrite and, if i am not mistaken, completely unaware that folks who read your rant will recognize that it is you, a cowardly, lonely, self-pittying troll, who is afraid to look in the mirror.

dear David,thank you for your service. I too get my care through the VA. perhaps you should actually read, reread, digest, and read a post again, sleep on it, write a draft of your response, have a friend read it to see if it makes sense, have someone edit it, throw it in the trash and then not post it. good day.